Training physicians in communication skills with adolescents using teenage actors as simulated patients

Communication skills Training physicians in communication skills with adolescents using teenage actors as simulated patients Daniel Hardoff 1 & Shifr...
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Communication skills

Training physicians in communication skills with adolescents using teenage actors as simulated patients Daniel Hardoff 1 & Shifra Schonmann2

1 Role-play exercises with simulated patients may serve the purpose of training professionals to develop appropriate communication skills with adolescents. Authentic adolescent responses toward the physicians may be achieved by actors who themselves are in their teenage years. We describe our experience in continuing medical education programmes for primary care physicians aimed at improving their skills in communicating with adolescents, using simulation methodology with teenage actors. Eight 16±17-year-old actors from the drama department of a high school for the arts were trained to simulate 20 cases with characteristic adolescent medical problems, as well as con®dentiality issues and home and school problems. The actors performed in front of large groups of 20±30 paediatricians, family practitioners, or gynaecologists in continuing medical education. Diagnostic issues as well as therapeutic and management approaches were dis-

Introduction The doctor±patient relationship remains at the core of the art of medicine. In addition to demonstrating clinical acuity, physicians ought to possess the necessary skills to assess patients' emotional needs and to display clear and effective responses to these needs.1 Lack of skill in the doctor±patient relationship may result in failure to reach the appropriate diagnosis, as well as to secure follow-up visits and compliance.2 A visit to the doctor is often upsetting and anxiety-producing,2 especially for adolescents who often experience dif®culties in expressing their concerns, and are

1 Division of Adolescent Medicine, Department of Paediatrics, Bnai Zion Medical Center, The Faculty of Medicine, Technion, Haifa, Israel 2 The Laboratory for Research in Theatre/Drama Education, The Faculty of Education, Haifa University, Haifa, Israel

Correspondence: D Hardoff, Director, Division of Adolescent Medicine, Department of Paediatrics, Bnai Zion Medical Center, P.O. Box 4940, Haifa, Israel

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cussed, while the actors provided feedback to the trainees about their understanding and their feeling regarding the issues raised during the exercises. Normally, smaller learning groups are more suitable for such training purposes; nevertheless the participants could appreciate learning the principles of careful listening, a non-judgmental approach and assuring con®dentiality. A collaboration of medical schools and postgraduate programmes with high schools which have drama departments may be fruitful in the teaching of adolescent medicine with special emphasis on communication skills with teenagers. Keywords Adolescence; communication; education, medical, continuing; education, medical, undergraduate; *physician patient relations; role playing. Medical Education 2001;35:206±210

reluctant to share feelings and con®dential matters with adults.3 The ability to create trustful relationships with adolescents in need of directed medical attention, together with success in obtaining useful information from them, demands special communication skills. Health professionals are under an obligation to serve as the adolescents' advocates, even when encountering rejection and hostility. In order to avoid expression of attitudes which may adversely affect the health interest of the adolescent patient, the health professional's feelings sometimes need to be carefully masked1 and acting can thus be the ultimate salvation for the caring physician.4 Communication skills are taught in most medical schools, allowing students to rehearse and to experiment, often by the use of simulation methods, including medi-drama where physicians also play the role of the patients,5,6 and by videotape scene analysis.7±9 Simulation exercises role-played by adult professional actors are accepted methods for both teaching and evaluation of clinical competence in medical schools worldwide.10±17 The use of adolescent actors in training professionals has not yet been reported.

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Training physicians in communication skills with adolescents

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D Hardoff & S Schonmann

Key learning points The ability to create trustful relationships with adolescents demands special communication skills. Simulation methodology with teenage actors confronting physicians to develop such skills is described. Theoretical discussions and feedback responses from the actors and the participant trainees follow each simulation. The authentic atmosphere of the experience is the core of the project, despite some momentary embarrassments. Collaboration of postgraduate medical programmes with adolescent drama students proves to be fruitful. Our project was introduced into existing continuing medical education programmes, for paediatricians, family physicians and gynaecologists, with the aim of improving physicians' skills in communicating with adolescents. We used simulation methodology, where students from the drama department of a high school for the arts played the patients' roles. Our assumption was that authentic adolescent responses during such exercises may be achieved by actors who themselves are in their teenage years.

Methodology Training the actors

Eight students, 16±17-year-olds from the drama department of WIZO high school for the arts in Haifa, were elected by their drama teachers to participate in the project. Informed consent for participation was obtained from their parents. The training of the young actors included the following. · A total of 20 case vignettes describing various med-

ical issues characteristic to adolescents were presented to the actors, from which each of them was asked to choose two or three to be role-played. A physician specializing in adolescent medicine (D.H.) provided the actors with medical background for the cases they had chosen and allowed an extensive discussion about these health issues with each student. A theatre specialist (S.S.) instructed the actors

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to build the characters of the patients within the context of family and social backgrounds. · The training required 10 preparatory sessions during which D.H. role-played the doctor and the students exercised improvisation skills. Re¯ective discussions with the two guiding professionals together with the young actors followed each exercise. The case vignettes

Several health issues were included in the vignettes, covering typical adolescent problems: pubertal developmental delay; gynaecomastia; dysfunctional uterine bleeding; pregnancy; eating disorders; chronic conditions such as obesity, asthma, diabetes mellitus and epilepsy; somatization conditions such as recurrent abdominal pain or headaches; cancer; mood disturbances; sexual abuse, and mental retardation. Con®dentiality issues as well as home and school problems were also included. The workshop set up

Each group of either paediatricians, family practitioners, or gynaecologists in continuing medical education (CME) consisted of 20±30 participants. The large size of the groups could not be reduced, because the CME programme was concise, and our project was only one learning unit within it. Splitting each group would have allowed only some of the participants to be exposed to the new experience. The exercise began with a doctor±patient role-play, during which one physician from the group volunteered to confront one young actor. The specialist in adolescent medicine in charge of the training would stop the role-play, either when the physician expressed a dif®culty in progression or when some medical or psychosocial issues needed to be clari®ed. At each `time out', the other participants commented and suggested different ways of proceeding with the interview. When the role-play was completed, the young actor and the doctor were asked to describe their feelings during the simulation. A theoretical discussion then took place, addressing relevant adolescent medicine issues. Each role-play and discussion took 30±45 minutes and usually two to three cases were exercised at each meeting.

Examples

To illustrate the methodology, three vignettes are presented and the course of the discussion is described:

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(a) A 14-year-old girl complains of tiredness and weakness for several weeks. Her appetite has decreased and lately she has refrained from going out with her friends at weekends. System review reveals frequent prolonged menstrual periods with blood clots. The presentation may be interpreted as associated with psychosocial problems, but the probable diagnosis of dysfunctional uterine bleeding resulting in severe anaemia points to the patient's complaints. Adolescent girls frequently feel uneasy about discussing issues relating to their menstrual periods, and this exercise is designed to improve communication with female adolescents about these issues. (b) A 15-year-old boy with asthma, who has been well on preventive therapy, complains of a recent exacerbation with frequent need for bronchodilator inhalations. History reveals decreased compliance with the preventive treatment in a very angry adolescent with over-protecting parents, who has recently started to smoke cigarettes. The case is simulated with another actor playing the parent, who would not let the adolescent stay alone with the physician. The ®rst phase of the exercise aims at creating a secure atmosphere to enable the mistrustful parent to leave the room. The second phase deals with building a trustful relationship between the doctor and the angry adolescent. Only then may the psychosocial review reveal the non-compliance with medical therapy and the commencement of cigarette smoking. The last part of the exercise addresses the dif®culty in convincing the patient not to smoke and to improve compliance. The whole exercise may be played several times with different doctors, illustrating alternative approaches. (c) A 17-year-old girl returns to her physician for a renewal of contraceptive pill prescription. She has no complaints regarding side-effects, but she admits that despite loving her boyfriend and desiring to have sexual relations she could not enjoy sex. Later in the interview she discloses that during childhood her father abused her sexually, and that she has never spoken about this matter with anyone before. This exercise aims at training physicians to address sexuality issues beyond the technical prescription of birth control pills and monitoring their side-effects.

Response At 1 month following the completion of a set of meetings, semi-structured questionnaires were used to evaluate the responses of the physicians in training and of the young actors. The physicians were requested to state advantages and drawbacks of confronting teenage actors in role-

play exercises in front of an audience of colleagues. They were also asked whether they had already introduced some changes in their approach toward adolescent patients in new encounters following the exercises. All participants agreed that this method demanded creative thinking and active learning, with regard to adolescent health issues, unlike formal lectures presented by experts. However, the majority admitted their reluctance to be exposed to a group of colleagues while playing the doctor's role. Those physicians who did role-play expressed their appreciation of the learning impact of the exercise after overcoming the embarrassment at the beginning of each simulation. They emphasized, however, the dif®culty in creating a trustful atmosphere with the simulated adolescent patients in front of the audience. The frank response from the young actor at the end of each simulation was a new experience, which was very much appreciated and was con®rmed as the most important take-home message. Their unanimous recommendation was to add role-play sessions with young actors to the CME programme in adolescent medicine. About half of the participants reported seeing adolescents in their clinics during the month following the exercise, and af®rmed their attempts to adhere to the principles which were learned during the simulation sessions, such as careful listening, a non-judgmental approach and assuring con®dentiality. The actors were requested to comment about the educational as well as the theatrical gains in this project. They were asked about dif®culties in playing the roles of unhealthy young people and in having to improvise alone in front of an unfamiliar adult audience. All the actors reacted positively to the experience of performing in front of professionals, and of being in the position of the `instructor' and not the trainee. Besides receiving much new information on medical issues, they could appreciate the fact that physicians have different viewpoints and doubts in various clinical situations, and that medicine is a multifaceted ®eld. From their past experience with their own primary care physicians, the actors appreciated the signi®cance of their role as facilitators in training physicians in communication with adolescents. From the theatrical point of view, the young actors, who are still drama students, felt that the unique experience in this project contributed to their skills in improvisation, within a framework of being actors and spectators at the same time.

Discussion Building a trustful adolescent±physician relationship is the cornerstone in the medical management of

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Training physicians in communication skills with adolescents

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teenagers, and the acquisition of skills in communication with them is therefore mandatory. In most medical schools limited periods are devoted to the study of adolescent medicine, and therefore continuing medical education (CME) remains the main framework for further training in adolescent health issues. Physicians' performance has been shown to improve in CME programmes which used the simulated-patient instrument.18 The use of role-play further facilitates active learning and increases self-con®dence.19 We describe a role-play method which enables physicians in CME training to acquire both knowledge concerning adolescent health issues, and skills in communication with teenagers. The advantages of this method relate to the fact that the actors themselves are adolescents, thus creating a more authentic atmosphere of the clinical situation during the exercise. The on-site response of the young actor contributes a signi®cant dimension to the understanding of the thought processes and the feelings of adolescents, regarding medical as well as psychosocial concerns and con®dentiality issues. The guidance of a specialist in adolescent medicine during the enacted role-play, and repeating the scenes with different emphases, enable the physicians in training to overcome communication obstacles and to appreciate alternative approaches to speci®c health issues. A few drawbacks to this method, as experienced in our project and also as re¯ected by the physicians' responses in the questionnaires, should be mentioned. Performing in front of a relatively large group of colleagues and receiving on-site response from the young actors created some embarrassment which might have inhibited the doctors from acting as naturally, as they would in their own clinics. In the ®rst moments of the exercise, the need to perform might distract a trainee from addressing appropriately the main health issues enacted in the role-play. However, as has also been stated by the physicians, the addition of such exercises, and working with smaller groups may improve the ef®cacy of this method. Indeed, such educational methods should normally be used in smaller learning groups, with clear group etiquette and support. The fact that the same case may be rehearsed several times with different approaches, and with different responses from the young actors, enhances the value of the use of simulated patients who are teenagers themselves. Since the exercise does not require objective evaluation of the trainees, the non-standardized simulation becomes an advantage. The unique use of teenage actors also bene®ts the actors themselves. They gain ®rst-hand knowledge on health issues, while at the same time they learn to

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appreciate that physicians have doubts and debates, and that postgraduate continuous learning is part of their professional lives. During the instruction of adults by young people con¯icts may sometimes develop. Therefore, monitoring by the professional leader may prevent unnecessary con¯icts and maintain a pleasant educational atmosphere. A different type of monitoring is mandatory, with regard to the personal lives of the young actors, who may be vulnerable to the emotional impact of the cases which they role-play. This is achieved by regular post-exercise communication with the specialist in adolescent medicine regarding the actors' feelings, thus reducing emotional upsets which may develop. The young actors also gain theatrical capacities regarding improved improvisation skills in reaction to audience responses, and in playing without a formerly prepared text. Our experimental project may be applied to any group of professionals working with adolescents. A collaboration of medical schools and postgraduate programmes with high schools that have drama departments may be fruitful in teaching adolescent medicine with special emphasis on communication skills with teenagers.

Acknowledgements Presented at the Youth Support Conference on Adolescent Medicine, at the Royal College of Medicine, London, October 1998.

References 1 Finestone HM, Conter DB. Acting in medical practice. Lancet 1994;344:801±2. 2 Silber TJ. Approaching the adolescent patient. Pitfalls Solutions. J Adolesc Health Care 1986;7:31s±40s. 3 Orr DP, Ingersoll GM. Adolescent development: a biopsychosocial review. Curr Probl Pediatr 1988;18:447±99. 4 McManus C. Department of theatrical medicine? Lancet 1994;344:767. 5 Yaffe MJ. The medi-drama as an instrument to teach doctor± patient relationships. Med Teacher 1989;11:321±9. 6 Helwig D. Memorial's dramatic dean: can drama help medical students learn? Can Med Ass J 1989;140:1364±5. 7 Gerbert B, Johnston K, Bleeker T, Bronstone A, Flatt S, Allerton M, et al. HIV risk assessment: a video doctor seeks patient disclosure. MD Comput 1997;14:288±94. 8 Aaraas I, Lundevall S, Njolstad I, Melbye H. Stuck with the patient ± what would my colleague have done? A video recorded consultation experiment with an actor simulating as the same patient for different doctors. Fam Pract 1993;10:43±5. 9 Feldman HA, McKinlay JB, Potter DA, Freund KM, Burns RB, Moskowitz MA, et al. Non-medical in¯uences on medical decision making: an experimental technique using videotapes,

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11

12

13

14

15

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factorial design, and survey sampling. Health Serv Res 1997;32:343±66. McManus IC, Vincent CA, Thom S, Kidd J. Teaching communication skills to clinical students. Br Med J 1993;306:1322±7. King A, Perkowski-Rogers L, Pohl H. Planning standardized patient programs: case development, patient training, and costs. Teaching Learning Med 1994;6:6±14. Brownwell Anderson M, Stillman P, Wang Y. Growing use of standardized patients in teaching and evaluation in medical education. Teaching Learning Med 1994;6:1±22. Pieters HM, Touw-Otten DeMelker RA. Simulated patients in assessing consultation skills of trainees in general practice vocational training: a validity study. Med Educ 1994;28:226±33. Evenson SA, Karterud SW, Mathisen P, Sekkelsten A. Assessment of medical students' ability to communicate unpleasant news. Tidsskr Nor Laegeforen 1997;117:2804±6. Finlay IG, Stott NC, Kinnersley P. The assessment of communication skills in palliative medicine: a comparison of

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17

18

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the scores of examiners and simulated patients. Med Educ 1995;29:424±9. Yano E, Tamiya N, Hasegawa T. Simulation exercises: a problem oriented method of learning public health in medical education. Nippon Koshu Eisei Zasshi 1998;45:270±8. Ridderikhoff J. Information exchange in a patient-physician encounter. A quantitative approach. Meth Inform Med 1993;32:73±8. Carney PA, Dietrich AJ, Freeman DH Jr, Mott LA. A standardized-patient assessment of a continuing medical education program to improve physicians' cancer-control clinical skills. Acad Med 1995;70:52±8. Kuipers JC, Clemens DL. Do I dare? Using role-play as a teaching strategy. J Psychosoc Nurs Ment Health Serv 1998;36:12±7.

2 Received 26 July 1999; editorial comments to authors 8 September 1999 and 13 March 2000; accepted for publication 31 March 2000

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